PFD report

Jason Mark BAYLEY · Prevention of Future Deaths report

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Issued 17 Oct 2023•Birmingham and Solihull

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
6

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised1

  1. Failure to accurately record medication adherence in shared clinical records
    Part of recurring concern: Incomplete, inaccurate or unavailable clinical and care records
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.6

  1. Action

    Audit medication-related Rio notes against ePMA records to assess the extent of inaccurate documentation.

    Stated by St Andrew's HealthcareStated in progressThe respondent said that this action was in progress when they made their response on 30 October 2023.
  2. Action

    Require Care Plan Update Meetings and ward rounds to review patients’ previous two weeks of ePMA medication records.

    Stated by St Andrew's HealthcareStated completedThe respondent said that this action was complete when they made their response on 30 October 2023.
  3. Action

    Investigate whether ePMA can alert responsible clinicians when consecutive medication doses are missed, including alert-fatigue effects.

    Stated by St Andrew's HealthcareStated in progressThe respondent said that this action was in progress when they made their response on 30 October 2023.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    Existing ePMA records, regular care reviews and the Patient Safety Dashboard adequately address risks from inaccurate medication information in Rio notes.

    Stated by St Andrew's HealthcareExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to accurately record medication adherence in shared clinical records

Wider context from the report

“2. On most days between 4/12/22 and 25/12/22 when he was a detained patient on Speedwell Ward at St. Andrew's Healthcare, Mr Bayley refused to take at least one of his daily doses of lactulose which he was prescribed as part of a regime of laxatives for constipation. While these refusals were documented in the Electronic Prescribing and Medicines Administration document, there were four occasions when it was incorrectly documented that all medication had been taken under the 'Medication Adherence' section in the Rio notes. 3. The Rio notes are the daily working records to which all staff have access. The reporting of medication adherence is specifically prompted in the Rio notes. It is of concern that, owing to a breakdown in communication between staff, the Rio notes repeatedly stated that all medication had been taken when it had not. 4. I am concerned that accurate documentation of whether medication has been taken in the Rio notes is an important safeguard against harm and a mechanism to promote appropriate care planning. I am concerned that there may be a risk to the life of some patients if staff understand that medication has been taken when it has not. ”

Is this part of a recurring concern?

Yes — Incomplete, inaccurate or unavailable clinical and care records.

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Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Audit medication-related Rio notes against ePMA records to assess the extent of inaccurate documentation.

Verbatim wording from the response

“4.1 In order to address the issue with the inaccuracy of the Rio notes that relate to medication the Charity is undertaking the following actions:”

Source location

Response from St Andrew's Healthcare
Page 3 · response
Published 30 October 2023

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Require Care Plan Update Meetings and ward rounds to review patients’ previous two weeks of ePMA medication records.

Verbatim wording from the response

“Action 3: Ensuring CPUMs review EPMA data 4.4 The Charity senior clinicians have communicated to their medical colleagues that every Care Plan Update Meeting/Ward Round should include a review of the last two weeks medication records on ePMA. This will ensure missed doses of medication will be noticed even if the Rio notes are incorrect.”

Source location

Response from St Andrew's Healthcare
Page 3 · response
Published 30 October 2023

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Investigate whether ePMA can alert responsible clinicians when consecutive medication doses are missed, including alert-fatigue effects.

Verbatim wording from the response

“4.6 In addition, the Charity is investigating if an ePMA can send a patient’s responsible clinician an alert if consecutive doses of medication are missed by a patient. In addition to the technical feasibility of this proposed development, the Charity also needs to consider the effect of ‘alert fatigue’ in the sense that the effectiveness of such alerts will be reduced if key clinicians receive too many alerts as they will start to be ignored.”

Source location

Response from St Andrew's Healthcare
Page 3 · response
Published 30 October 2023

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Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Assess whether ePMA can automatically create Rio progress notes documenting medication administration events.

Verbatim wording from the response

“Action 4: Investigating a technical solution 4.5 The Charity is currently undertaking a project to consider if ePMA can automatically make a Rio progress note documenting medication administration events. This would negate the need for this information to be included in the shift summary notes.”

Source location

Response from St Andrew's Healthcare
Page 3 · response
Published 30 October 2023

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Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Speak with colleagues who made inaccurate entries and remind them during management supervision about accurate record keeping.

Verbatim wording from the response

“3.1 Having compared the missed doses of lactulose with the inaccurate Rio notes we have noted that on every occasion the Rio note was made by a colleague who was different to the one who administered the medication. During this period, where Mr Bayley missed a dose of lactulose and the Rio note documenting the shift handover was made by the person who administered his medication the Rio note is accurate. The staff making these notes vary in seniority from healthcare assistants to a deputy ward manager.”

Source location

Response from St Andrew's Healthcare
Page 2 · response
Published 30 October 2023

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Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Disseminate messages to all colleagues on accurate record keeping and documenting missed medication doses in Rio.

Verbatim wording from the response

“Action 2: Reminding staff of the importance of good record keeping 4.3 The Charity has a weekly clinical briefing called the Pulse which is received by all colleagues. We have included a message on the importance of accurate record keeping as well as another on the importance of documenting in Rio if a patient misses a dose of medication.”

Source location

Response from St Andrew's Healthcare
Page 3 · response
Published 30 October 2023

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Existing ePMA records, regular care reviews and the Patient Safety Dashboard adequately address risks from inaccurate medication information in Rio notes.

Verbatim wording from the response

“5.3 We would also highlight that you may not have been provided with detailed information of how the Charity’s EPR systems operate and are reviewed, which would have given you a better understanding of how the ePMA is used by clinicians. The Charity’s position is that the prominent system for checking the prescribing and administration of medication is ePMA which is regularly checked by doctors and is used by nurses at every instance of medication administration. There are therefore controls in place which address the risk of incorrect information about medication administration being entered into the progress notes of Rio, which is not the main system for medication management.”

Source location

Response from St Andrew's Healthcare
Page 3 · response
Published 30 October 2023

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    The missed lactulose doses contributed no more than minimally or trivially to death, given other laxatives and chronic constipation management.

    Stated by St Andrew's HealthcareDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

The missed lactulose doses contributed no more than minimally or trivially to death, given other laxatives and chronic constipation management.

Verbatim wording from the response

“1.3 I think it is also worth stressing that the evidence you heard at the inquest – from witnesses at the Charity and Queen Elizabeth Hospital – is that Mr Bayley received all of the dosages for the two other laxatives he was prescribed and the missed dosages of lactulose over a period of 4 weeks did not more than minimally or trivially contribute to his death. The witnesses you heard from the Queen Elizabeth Hospital outlined that Mr Bayley’s issue with constipation was a chronic problem that had probably developed over a number of years during which time Mr Bayley’s physical health had been monitored appropriately and included a high number of referrals to specialists at the Queen Elizabeth Hospital.”

Source location

Response from St Andrew's Healthcare
Page 1 · response
Published 30 October 2023

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026